Inspection report for University Hospital Llandough

HIW made an unannounced inspection to University Hospital Llandough between October 11 and 12.

Inspectors found the hospital to be clean and staff treated patients with respect and kindness.

However, the health board noted that some of the employer’s written procedures need to be updated and appointment letters need to be made bilingual with the text size increased due to some patients having difficulty reading the letters.

Inspection report for University Hospital Llandough (Image: Street View)

Inspection report for University Hospital Llandough. Picture: Street View

The report included the main suggestion for improvement made by patients was to increase the space available for both waiting and treatment areas.

Inspectors identified that the hospital had good compliance with The Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2017 but the written agreement provided to HIW under the delivery of Safe and Effective care had expired in March 2022.

Delivery of Safe and Effective Care-What the service did well:

• Local Diagnostic Reference Levels had been established and these were below National Diagnostic Reference Levels.
• Senior staff demonstrated a good understanding of the differences between clinical audit and IR(ME)R audit and we saw improvements had been made as a result of audit activity.
• Useful information on infection prevention and control matters and audit results was clearly displayed in the department for patients to see.

Delivery of Safe and Effective Care- HIW’s recommended improvements:

• Some of the employer’s written procedures need to be updated and clearly show when they have been reviewed and the date for next review.
• The equipment inventory needs to include all the equipment used in the department.
• The third-party written agreement for radiation protection services, including MPE support, needs to show it has been formally renewed and is current.
• Consideration should be given to developing written action plans following audit activity to demonstrate an analysis has been done and to capture the action taken/to be taken and follow up activity.

Out of 27 patients questioned on waiting times 22 of the 27 said they had to wait less than 15 minutes to have their procedure, 3 waited between 15 and 30 minutes and 2 waited for more than 30 minutes.